Table 6.

Concluding remarks on technical steps for advancement flap on perianal fistulizing Crohn’s disease

Step	Conclusions
Patient selection	On optimized medical treatment (biological therapy)
	No active proctitis, minimal luminal inflammation
	No or minimal anal canal stenosis (anal fistulas)
Timing	Fistula adequately drained with no signs of inflammation
	No major cephalic extensions, secondary tracts, or cavities of granulation tissue
	Wait for the medical treatment to take effect
Intraoperative remarks	Thorough dissection of a tension-free flap and preparation of a landing zone may be challenging—discontinue if significant fibrosis is present beneath the mucosa
	Precise eradication of the IO and proper closure of the fistula tract
	Minimize dead space
	Consider core-out of the EO and fistula tract up to the sphincter
Postoperative remarks	Plan the first follow-up in 3–4 months—if no signs of infection, re-evaluate clinical healing 6–12 months postoperatively
	Optimal medical treatment continued
	If complete clinical healing at 12 months, consider assessing radiological healing on MRI at 18 months before reducing medication

IO, internal orifice; EO, external orifice; MRI, magnetic resonance imaging